Nicotine & Tobacco Research, 2016, 1061–1066
doi:10.1093/ntr/ntv148
Original investigation
Advance Access publication July 7, 2015
Original investigation
Differences in Longer-Term Smoking Abstinence
After Treatment by Specialist or Nonspecialist
Advisors: Secondary Analysis of Data From a
Relapse Prevention Trial
Fujian Song PhD1, Vivienne Maskrey MSc1, Annie Blyth MA1,
Tracey J. Brown MMedSci1, Garry R. Barton PhD1,2, Paul Aveyard PhD3,
Caitlin Notley PhD1, Richard Holland PhD1, Max O. Bachmann PhD1,
Stephen Sutton PhD4, Thomas H. Brandon PhD5
Norwich Medical School, University of East Anglia, Norwich, United Kingdom; 2Norwich Clinical Trial Unit, University
of East Anglia, Norwich, United Kingdom; 3Nuffield Department of Primary Care Health Sciences, University of
Oxford, Oxford, United Kingdom; 4Institute of Public Health, University of Cambridge, Cambridge, United Kingdom;
5
Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL
1
Corresponding Author: Fujian Song, PhD, Norwich Medical School, University of East Anglia, Norwich, Norfolk, NR4 7TJ,
United Kingdom. Telephone: 44-(0)1603-59-1253; E-mail: [email protected]
Abstract
Introduction: Smokers receiving support in specialist centers tend to have a higher short-term quit
rate, compared with those receiving support in other settings from professionals for whom smoking cessation is only a part of their work. We investigated the difference in longer-term abstinence
after short-term smoking cessation treatment from specialist and nonspecialist smoking cessation
services.
Methods: We conducted a secondary analysis of data from a randomized controlled trial of selfhelp booklets for the prevention of smoking relapse. The trial included 1088 short-term quitters
from specialist stop smoking clinics and 316 from nonspecialist cessation services (such as
general practice, pharmacies, and health trainer services). The difference in prolonged smoking abstinence from months 4 to 12 between specialist and nonspecialist services was compared. Multivariable logistic regression analyses were conducted to investigate the association
between continuous smoking abstinence and the type of smoking cessation services, adjusted
for possible confounding factors (including demographic, socioeconomic, and smoking history
variables).
Results: The proportion of continuous abstinence from 4 to 12 months was higher in short-term
quitters from specialist services compared with those from nonspecialist services (39% vs. 32%;
P = .023). After adjusting for a range of participant characteristics and smoking variables, the specialist service was significantly associated with a higher rate of longer-term smoking abstinence
(odds ratio: 1.48, 95% CI = 1.09% to 2.00%; P = .011).
Conclusions: People who receive support to stop smoking from a specialist appear to be at lower
risk of relapse than those receiving support from a nonspecialist advisor.
© The Author 2015. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco.
This is an Open Access article distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivs licence (http://creativecommons.
org/licenses/by-nc-nd/3.0/), which permits non-commercial reproduction and distribution of the work, in any medium, provided the original work is not altered
or transformed in any way, and that the work is properly cited. For commercial re-use, please contact [email protected]
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Introduction
Behavioral and pharmacological interventions are effective for smoking cessation in smokers who are motivated to quit.1 Since 2001, a
national network of NHS stop smoking services has been established
in England to provide behavioral support and pharmacotherapy to
smokers who would like to quit.2 In 2012/2013, the English stop
smoking services provided support to 724 247 quit attempts, and
generated 265 140 biochemically validated quitters (37% of quit
attempts) at 4 weeks after the quit date.3
In the English stop smoking services, smokers motivated to quit
may receive support in specialist clinics, primary care, pharmacy,
or other settings.3 Previous studies reported that smokers receiving
support in specialist centers tended to have a higher quit rate at 4
weeks after quit dates, compared to those receiving support in other
settings from professionals for whom smoking cessation was only a
part of their work.4,5 However, a recent study using routine monitoring data found little difference in quit rates between different types
of smoking cessation advisors, except that smoking cessation support by nurses tended to be less effective than by specialist advisors.6
Previous studies have only compared short-term smoking outcomes.
For longer-term smoking outcomes, it has been assumed that the rate
of smoking relapse would be similar among short-term quitters, irrespective of the type of smoking cessation support provided.4,5,7 There
is a lack of evidence to compare the longer-term smoking outcomes
between different types of smoking cessation advisors.
In a randomized controlled trial of self-help materials for smoking relapse prevention (ISRCTN: 36980856),8 we recruited 1407
short-term quitters and conducted follow-up interviews at 3 and
12 months after quit dates. Participants in the treatment group
received a set of eight self-help booklets for relapse prevention, and
those in the control group were sent a single leaflet that is currently
used in practice. It was found that there was no difference between
the intervention groups in prolonged smoking abstinence from
month 4 to 12 (37% vs. 39%, P = .51), and main findings of the trial
will be published elsewhere.9 In the trial, we also collected data on
the type of stop smoking services (specialist services, or from general practice nurses, pharmacists, or community health trainers). In
a secondary analysis, we examined whether there was a difference in
longer-term smoking abstinence at 12 months between quitters who
received smoking cessation treatment in different settings.
Methods
Study Participants
Study participants were those included in a randomized controlled
trial of self-help material for smoking relapse prevention.9 The target population for this trial was people who had stopped smoking,
as verified by carbon monoxide (CO) reading, at 4 weeks after the
quit date, following the provision of cessation support from NHS
stop smoking services. The biochemically verified 4-week quitter is
defined as a treated smoker who reports abstinence from at least day
14 after the quit date to the 4-week follow-up point and who blows
an exhaled CO reading of less than 10 ppm.10 Quitters who were
pregnant, unable to read booklets in English, from families at the
same address, or younger than 18 years were excluded.
We recruited CO-validated short-term quitters from August
2011, and initially recruited participants only from specialist
stop smoking clinics. In May 2012, participant recruitment was
expanded to other settings, including pharmacies, general practice, and health trainer services. Smoking cessation advisors in
Nicotine & Tobacco Research, 2016, Vol. 18, No. 5
specialist stop smoking centers are more highly trained in delivering smoking cessation interventions.4 In contrast, smoking cessation counseling is only a small part of the role of practice nurses
and pharmacists. Health Trainers also have a wider role, providing
general support for health behavioral changes, including stopping
smoking, dietary changes, reducing alcohol intake, and increasing
physical activity.11
The trial achieved the recruitment target by June 2013, and
included a total of 1407 eligible short-term quitters. Three participants died before the 12-month follow-up and were excluded from
the analysis. Of the 1404 participants, there were 1088 participants
from specialist stop smoking clinics, and 316 from nonspecialist cessation services (including 220 from general practices, 57 from health
trainers, and 39 from pharmacy). The follow-up rate was 86% at
12 months, and the rate of CO verification was 85% for participants
who reported abstinence at the 12-month follow-up.
Data Collection and Variables
Four weeks after the quit date, stop smoking advisors gathered baseline information from participants who had consented to participate
in the study, including participants’ demographic characteristics and
smoking history (including previous quit attempts, number of cigarettes per day, time of the first cigarette after waking up, living with
a smoking partner or not). Study participants were then followed up
by researchers at 3 and 12 months after quit dates. The follow-up
interviews were conducted by telephone and involved researchers
administering a questionnaire which asked questions about the participant’s smoking status and process variables. In addition, at the 3
and 12-month follow-up, we asked participants whether they used
smoking cessation medications during 2 and 3 months after the quit
date (For more details about questions asked and response options,
please see the baseline and follow-up questionnaires in an online
Supplementary Material.).
The primary outcome in the study was defined as prolonged
abstinence from months 4 to 12, with no more than five cigarettes
in total, and confirmed by CO < 10 ppm at the 12-month followup.12 At the 12-month follow-up, participants who reported smoking abstinence during the past 7 days were invited to take a CO test.
Participants came to a clinic or a researcher visited them at home
for this test. To optimize CO test rates, a shopping voucher (£20)
was offered to each of the participants who attended the CO test
at the 12-month follow-up. Participants who declined biochemical
verification or who did not respond to follow-up were classified
as relapsed. However, according to the trial protocol8 and Russell
standard,12 participants who died or were known to have moved
away from the study areas were excluded from the numerator and
denominator, because their smoking status were not available at the
final follow-up.
Statistical Analysis
We used t test for continuous variables and Pearson chi-square test
for categorical variables to compare differences between stop smoking services in baseline characteristics and the use of cessation medications. The statistical significance was defined when the P value was
at most 5%. We used multivariable logistic regression analyses to
investigate the association between continuous smoking abstinence
from 4 to 12 months and the type of smoking cessation services
participants had accessed, adjusted for possible confounding factors.
The confounding factors used in the multivariable analysis were age,
Nicotine & Tobacco Research, 2016, Vol. 18, No. 5
1063
sex, married or living with a partner, education level, unemployed
or not, receipt of free prescription, previous quit attempts, managed
to quit at least 4 weeks before, less than 10 cigarettes per day, first
cigarette within 5 minutes after waking, living with a smoking partner, use of nicotine replacement therapy (NRT) or varenicline during
2 to 3 months after the quit date. The dependent variable was the
prolonged CO-validated smoking abstinence from 4 to 12 months,
and independent variables included type of stop smoking advisors
(specialist vs. other), age, gender, marital status, level of education,
in receipt of free prescription, previous quit attempts, level of nicotine dependence, and use of smoking cessation medications during 2
to 3 months after the quit date. Statistical analyses were conducted
using Stata (version 13.1).
Results
The main characteristics of participants by type of service are shown
in Table 1. There were no statistically significant differences between
participants from specialist services and nonspecialist services in
demographic characteristics and smoking variables at baseline. The
average age of participants was 48 years, and 53% were female.
The proportion of participants who were unemployed was 10%, and
57% were in receipt of free prescriptions. Most (89%) had previously attempted to quit smoking, and 18% were living with a smoking partner (Table 1).
Table 2 shows the use of smoking cessation medications during 2 and 3 months after the quit date. There were no statistically
significant differences between specialist and nonspecialist services
(as a combined category) for the use of any medications (74.2% vs.
72.5%), NRT (36.3% vs. 36.4%), or varenicline (40.6% vs. 36.4%).
However, there were statistically significant differences in the use of
NRT or varenicline across individual settings (Table 2). For example,
participants from pharmacy settings were more likely to use NRT
compared to participants from general practice (61.5% vs. 30.9%).
The use of varenicline was 0.0% in participants from pharmacy settings, compared to 44.6% in those from general practice settings.
Figure 1 shows the rate of continuous abstinence from 4 to
12 months by type of stop smoking service, which was relatively high
for specialist services (39.3%, 95% confidence interval [CI] = 36.5%
to 42.3%), low for health trainers (28.1%, 95% CI = 17.7% to
41.5%) or pharmacies (28.2%, 95% CI = 15.9% to 44.9%), and
intermediate for GP practices (34.1%, 95% CI = 28.1% to 40.7%).
When nonspecialist services were combined, the rate of continuous
smoking abstinence was higher in participants recruited from specialist services in comparison to the rate of abstinence in participants
from nonspecialist services (39% vs. 32%; P = .023). If the outcome
was defined as continuous abstinence from month 2 to 12, the difference in abstinence rate between specialist and nonspecialist services
would be similar (34% vs. 27%; P = .018).
Results of multivariable logistic regression analysis are shown in
Table 3. After adjusting for a range of participant characteristics and
smoking variables, the specialist service was significantly associated
with a higher rate of longer-term smoking abstinence (odds ratio:
1.48, 95% CI = 1.09% to 2.00%; P = .011). The longer-term smoking abstinence rate was positively associated with age (P = .016),
married or living with a partner (P = .003), fewer than 10 cigarettes per day before quitting (P = .001), and use of NRT during
2–3 months (P = .001). Unemployment status (P = .056), smoking
the first cigarette within 5 minutes after waking up (P = .068), and
use of varenicline during 2–3 months (P = .060) tended to be associated with the longer-term smoking outcome, although the association was not statistically significant (Table 3).
Table 1. The Participant Characteristics at Baseline by Service Type
Specialist smoking cessation
services (N = 1088)
Age: mean (SD)
Female: % (n)
Ethnicity—white: % (n)
Married or living with a partner: % (n)
Education: % (n)
None
GCSE
A-level
Degree
Unknown
Employment status: % (n)
Paid employment
Unemployed
Looking after home
Retired
Full time students
Other
Free prescriptiona: % (n)
Any previous quit attempts: % (n)
Cigarettes <10 per day before quitting: % (n)
First cigarette within 5 minutes after waking up: % (n)
The longest time managed to stay quit before, >4 weeks: % (n)
Living with a smoking partner: % (n)
Nonspecialist smoking
cessation services (N = 316)
P
48.1 (13.9)
52.4 (570)
98.6 (1070)
62.6 (680)
(N = 1074)
20.4 (219)
34.5 (371)
17.8 (191)
14.6 (157)
12.7 (136)
47.0 (13.2)
53.8 (170)
98.7 (312)
58.5 (185)
(N = 312)
19.6 (61)
34.9 (109)
14.7 (46)
18.3 (57)
12.5 (39)
.182
.659
.875
.190
50.9 (554)
10.5 (114)
7.8 (85)
20.7 (225)
1.5 (16)
8.6 (94)
58.0 (625/1077)
88.6 (963/1087)
13.5 (147/1087)
42.9 (466/1087)
72.6 (756/1041)
18.2 (198)
58.9 (186)
8.5 (27)
6.0 (19)
18.4 (58)
0.3 (1)
7.9 (25)
53.5 (165/310)
91.1 (288/316)
15.8 (50/316)
39.9 (126/316)
67.8 (213/314)
19.0 (60)
.135
.479
.132
.200
.300
.342
.099
.750
GCSE = General Certificate of Secondary Education.
a
Free prescription—The charge for a single prescription is £8.05 in the United Kingdom. Some people are entitled to free prescriptions because of their age (60 or
over, or under 16, or aged 16 to 18 in full-education), income (on Income Support or qualified via other benefits or tax credits), or medical condition.
Nicotine & Tobacco Research, 2016, Vol. 18, No. 5
1064
Table 2. Use of Stop Smoking Medications During 2–3 Months
Any cessation
medications % (n)
Any nicotine
replacement therapy % (n)
Varenicline % (n)
Total N
74.6 (812)
72.5 (229)
74.6 (164)
70.2 (40)
64.1 (25)
74.2 (1041)
36.3 (395)
36.4 (115)
30.9 (68)
40.4 (23)
61.5 (24)
36.3 (510)
40.6% (442)
36.4 (115)
44.6 (98)
29.8 (17)
0 (0)
39.7 (557)
1088
316
220
57
39
1404
P = .439
P = .977
P = .176
P = .445
P = .003
P < .001
Specialist services
All nonspecialist services
General practice
Health trainer
Pharmacy
Total
Pearson chi-square test:
Specialist services vs. all
nonspecialist services
Across different settings
(specialist, general practice,
health trainer, and pharmacy)
Some participants used more than one cessation medication during 2–3 months. The number of participants who did not use any cessation medications was the
difference between the total number of participants and the number of participants who used any cessation medications. For example, 276 of the 1088 participants
from specialist services did not use any cessation medications (ie, 1088 − 812 = 276).
Smoking absnence
at 12 months (%)
50%
40%
39%
34%
30%
28%
28%
Pharmacy
(n=39)
Health Trainer
(n=57)
20%
10%
0%
Specialist
service
(n=1088)
GP Pracce
(n=220)
Figure 1. Continuous abstinence from 4 to 12 months in short-term quitters,
by type of smoking cessation advisors.
Discussion
To the best of our knowledge, this is the first large scale study showing that short-term quitters after receiving cessation treatment from
specialist advisors were less likely to relapse at 12 months compared
to those treated in nonspecialist services. The difference in the proportion of smoking abstinence at 12 months was on average 7%
between the specialist and nonspecialist services, which has important public health implications. Assuming the same quit rate (37%)
at 4 weeks after the quit date,3 the corresponding rate of prolonged
abstinence from month 4 to 12 in people who set a quit date will
be 14.4% and 11.8%, respectively. The difference in prolonged
abstinence among people who set a quit date is likely to be larger
than 2.6% if the support from specialist advisors is associated with
a higher short-term quit rate than the support from nonspecialist
advisors.4
The observed difference in longer-term smoking abstinence
between specialist and nonspecialist services in this study is unlikely
to be caused by confounding factors. The association between smoking abstinence at 12 months and support from specialist advisors
remained statistically significant after adjusting for participant characteristics, smoking history variables, and the use of smoking cessation medications (Table 2).
Previous studies have explored possible reasons for varying
short-term outcomes by different smoking cessation settings and
type of advisors in the English stop smoking services. Firstly, specialist advisors have received more training in smoking cessation counseling, compared to other health care professionals,13 and a study
found that success rates of smoking cessation treatment were associated with increased uptake of a national evidence-based training
programme by advisors.14 In addition to more extensive training,
McDermott and colleagues4 reported that specialist advisors received
more supervision and showed greater adherence to evidence-based
practice. Finally, it was found that group based sessions were more
common in specialist centers than in other settings,5 and support
provided in specialist clinics may be more intensive, compared to
that provided in nonspecialist settings. For example, smoking cessation treatment delivered by pharmacists in Glasgow was considered
to be of “medium-intensity”.15
The above reasons may also be pertinent in explaining the
reduced risk of longer-term smoking relapse in short-term quitters
who received support in specialist centers. Compared with nonspecialist support, behavioral support from specialist advisors might
have provided more effective knowledge and skills for clients to
cope with urges to smoke. It was found that reported attempts
by participants to do something to cope with urges were associated with a lower risk of smoking relapse.9 We further analyzed
data and found that the proportion of participants who attempted
to do something to cope with urges was 89.9% in participants
from the specialist services and 84.5% in those from nonspecialist
services.
Limitations
This was a secondary analysis of data from a trial, and it is possible that the effects observed are due to confounding factors that
were not measured or adjusted for. The study recruited many more
short-term quitters from specialist services (n = 1088) than from
nonspecialist services (n = 316). Therefore, quitters from pharmacies, general practice, and health trainer services were combined in
the main analysis and a comparison between different nonspecialist
settings could not be conducted because of the small sample size. It
also raises a question about the sample’s representativeness to all
short-term quitters from nonspecialist smoking cessation services.
Nicotine & Tobacco Research, 2016, Vol. 18, No. 5
1065
Table 3. Results of Multivariable Logistic Regression for Continuous Smoking Abstinence From 4 to 12 Months
Specialist services vs. nonspecialist services
Age (y)
Female vs. male
Married or living with a partner vs. all other
Low education (up to GCSE vs. A-level or above)
Unemployed vs. all other
Free prescription vs. no free prescription
Any previous quit attempts vs. no previous quit attempt
Longest time managed to quit before: >4 weeks vs. ≤4 weeks
Cigarettes per day before quitting: <10 vs. ≥10
First cigarette within 5 minutes after waking vs. >5 minutes
Living with a smoking partner vs. not living with a smoking partner
Use of NRT vs. no use of NRT during 2–3 months
Use of varenicline vs. no use of varenicline during 2–3 months
Odds ratio (95% CI)
P
1.477 (1.092, 1.997)
1.013 (1.002, 1.023)
0.933 (0.723, 1.205)
1.520 (1.158, 1.995)
0.940 (0.726, 1.218)
0.634 (0.398, 1.012)
0.898 (0.675, 1.195)
0.702 (0.439, 1.123)
1.770 (1.245, 2.517)
0.785 (0.605, 1.018)
0.817 (0.586, 1.140)
0.888 (0.639, 1.236)
1.652 (1.214, 2.248)
1.335 (0.987, 1.805)
.011
.016
.596
.003
.641
.056
.461
.140
.001
.068
.235
.480
.001
.060
CI = confidence interval; GCSE = General Certificate of Secondary Education; NRT = nicotine replacement therapy. The multivariable analysis used data from
1154 participants, and data from 250 participants were excluded from the analysis because of missing data from some independent variables. After including the
treatment condition as an independent variable, the results of the logistic regression analysis remain materially unchanged.
In addition, the level of training and experience amongst staff who
provide smoking cessation support in pharmacies, general practice,
and health trainer services may be very different.
In summary, longer-term smoking relapse appeared to be reduced
in smokers who received support from specialist smoking cessation
advisors, compared with those who received support from nonspecialist advisors.
Implications for Practice and Research
Findings from this study suggest that support from specialist smoking cessation advisors is associated with not only an increased shortterm quit success, but also a reduced longer-term smoking relapse
risk among short-term quitters. The most meaningful public health
target of smoking cessation programmes is a lowered prevalence
of smoking in population, rather than simply a counting of shortterm quitters most of whom will relapse in 12 months. Although
smoking cessation support in any setting is cost-effective,16 specialist
counseling, as an intervention that improves longer-term outcomes,
should be emphasized.
Findings from this study have important public health and
clinical implications, as currently there is a lack of cost-effective
interventions for the prevention of smoking relapse in short-term
quitters.17,18 In the English stop smoking services in 2012/2013,
33% of smokers motivated to quit received support in specialist
clinics, 39% in primary care, 21% in pharmacy, and 7% in other
settings.3 The total number of people who set a quit date in nonspecialist services was 485 245 in 2012/2013 in England.3 If the rate
of prolonged abstinence was increased by 2.6%, there would be 12
616 more people who were abstinent at 12 months. Therefore the
use of specialist smoking cessation services should be encouraged
to result in more quitters with longer-term abstinence. However, it
should be stressed that smoking cessation support from nonspecialist advisors is still cost-effective.16 A large proportion of smokers
motivated to quit have chosen to receive cessation support from
general practice, pharmacy, and other nonspecialist advisors, based
on individual preferences, such as perceived convenience. Health
care professionals who provide smoking cessation counseling in
nonspecialist settings should receive more training, or be allowed
more time to provide smoking cessation counseling, in order to
improve short-term and longer-term outcomes. Further research is
needed to investigate reasons for the difference in longer term outcomes between specialist and nonspecialist cessation support, and
whether enhancing generalist skills in nonspecialist advisors can
reduce longer term relapse.
Supplementary Material
Supplementary Material can be found online at http://www.ntr.
oxfordjournals.org
Funding
This project was funded by the NIHR Health Technology Assessment programme (Project HTA09/91/36). Visit the HTA programme website for more
details www.hta.ac.uk/link to project page. The views and opinions expressed
therein are those of the authors and do not necessarily reflect those of the
Department of Health. We acknowledge the support of the National Institute
for Health Research, through the Primary Care Research Network. PA is funded
by UK Centre for Tobacco Control Studies (a UKCRC Public Health Research
Centre of Excellence) which receives funding from British Heart Foundation,
Cancer Research UK, Economic and Social research Council, Medical Research
Council, and the Department of Health (grant number MR/K23195/1).
Declaration of Interests
PA has done ad hoc consultancy and research for the pharmaceutical industry
on smoking cessation. THB has received research funding and study medication from Pfizer, Inc. No other competing interest declared; no other relationships or activities that could appear to have influenced the submitted work.
Acknowledgments
FS, PA, THB, RH, GRB, MOB, and SS designed the trial and developed study
protocol. VM and AB coordinated the trial and contributed to project management. AB, VM, TJB and CN contributed to participant recruitment, follow-up
interviews, and data collection. FS analyzed data and drafted the manuscript.
All authors contributed to the interpretation of results, and commented on the
draft manuscript. We thank staff from NHS Norfolk and Norfolk Community
Health & Care NHS Trust for providing advice on the development of the trial
protocol. We thank stop smoking advisors from NHS stop smoking services in
Norfolk, Lincolnshire, Suffolk, Hertfordshire, Great Yarmouth, and Waveney
for recruiting quitters to the study. The trial was conducted in collaboration
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with the Norwich Clinical Trials Unit whose staff provided input into the
design, conduct and analysis (Tony Dyer—randomization and data management, Garry Barton—health economics). We thank Laura Vincent for providing administrative support, data entering and data checking.
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